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Review

Review. I guide for studying…. Ground Rules. This review is not all-inclusive You are still responsible for: Extra notes, comments added in class to clarify a concept, etc…. “Wellness Care”. Fysh’s Wellness Schedule Developmental Surveillance (define)

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Review

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  1. Review I guide for studying…

  2. Ground Rules • This review is not all-inclusive You are still responsible for: • Extra notes, comments added in class to clarify a concept, etc…

  3. “Wellness Care” • Fysh’s Wellness Schedule • Developmental Surveillance (define) • Why use screening tools vs. observation? • Are parent’s good judges of developmental delays? Why?

  4. Age Descriptors • Newborn birth to 2 months • Infant 0-1 year • Toddler 1-2 years • Child 2+ years

  5. History “Historian” • Name • Relationship to the patient • Reliability

  6. Infant Vitals • Pulse • Apical pulse – 5th intercostal space, midclavicular line • Compare brachial to femoral • Respiration • Look at abdomen • Signs of distress? • BP • Temp • Tympanum vs. axillary (newborn-don’t add 1) • *Height – recumbent (top of head to heel) • *Weight - oz

  7. Weight • Doubles by 6 months • Triples by 1 year Head & Chest Circumference • Where do you measure? • <2 years: approx. the same

  8. Large head = hydrocephalus • Small head = microcephaly (craniosynostosis) • Lack of growth, weight gain • Failure to thrive?

  9. Skin Variants (Pigment? Vessels? Temp? Etc?) • Acrocyanosis (transient) • Cutis marmorata • Mongolian spots • Telangiectatic nevi • Erythema toxicum • Milia/miliaria • Strawberry hemangioma

  10. Skin Findingsto Investigate Further… • Persistent acrocyanosis • Faun-tail nevus (spina bifida) • Café-au-lait (neurofibromatosis) • Port-wine stain (opthalmic CN V) • Jaundice

  11. Jaundice • Tips for examining… • Risk factors • Physiologic vs Pathological • Rh incompatibility?

  12. Immune/Lymph • Firm, discrete, moveable (visible) • <0.5cm “normal” Investigate further if: • Growing rapidly • Suspiciously large (>2-3 cm) • Fixed and immoveable

  13. Tonsils • Enlarged? • At what are do they “peak” in their “relative size”? • Possible complication: • ____________ • Grading +2

  14. Newborn Head & Neck • Molding and prominent ridges (birth) usually resolved within 1 week

  15. Fontanels • Post fontanel: ~2 months • Ant fontanel: by 24 months • Measure: transvere +AP 2 • Bulging • Infection? • Increased ICP? • Depressed • Dehydration? • other signs of dehydration

  16. Hydrocephalus Signs & Symptoms

  17. Eyes • Red reflex (newborn +) • Retinoblastoma • Cataracts • Strabismus (exo, eso) vs pseudostrabismus • Corneal light reflex • Cover-uncover • Cross Cover • Adult visual acuity is developed ~6 years (20/20)

  18. Nose • External • Internal • Shine a light • Tilt the nose tip up with thumb • Patency?

  19. Infant Mouth Exam • Avoid depressing the tongue • Stimulates reflex protrusion - unable to visalize • Tongue • Fits in mouth (macroglossia?) • Can protrude past gums (short frenulum?) • Strong suck; gag reflex • Palate well-formed • Thrush vs milk?

  20. Child Mouth Exam • To get a child’s mouth open: • May have to gag them • Grading Tonsils (1+ to 4+) • Peak size 2-6 years old

  21. Strep pharyngitis • S & S? • NO cough

  22. Child Ear Exam • Restraining? (red reflex) • Sit on parent’s lap • Pull ear down and back OR up and back (child) • Pneumatic otoscopy • Tympanometry • Acoustic reflectometry

  23. Hearing Note… Speech development and hearing go hand in hand • Toys, voice • Weber, Rinne, Schwabach • 3-4 years old

  24. Newborn Chest Exam • Periodic breathing • Prolonged? Cyanotic? Newborn • Cough – concern • Sneezing – normal

  25. Chest Exam • Crackles • Stridor • Grunting Increased Respiratory Effort • Retraction (ribs, supraclavicular notch) • Contraction of SCM’s • Flaring of nostrils • Paradoxic breathing

  26. Chest Exam (Child) • Breath sounds may be louder, harsher, and more bronchial • Hyperresonance is common • Easy to miss dullness (consolidation)

  27. Asthma • Hyperreactivity • COPD • Signs and symptoms: • Anxiety • Wheezing • Dyspnea • Cough • Prolonged expiratory phase

  28. For each condition… • Know typical signs & symptoms • Clinical presentation • Expected resolution? • Treatment?

  29. Infant Heart Exam • Heart function… • Skin • Lungs • Liver • Apical pulse (rate) • Brachial vs femoral • Weak, thin, bounding? • Capillary refill

  30. Most murmurs are innocent • Investigate if: • Persists beyond 2-3 days of life • Intense • Fills systole • Occupies diastole • Radiate widely • Cyanosis = referral

  31. Congenital Heart Defects • Which ones result in cyanosis? • Tetralogy of Fallot

  32. Abdominal Exam • Infant normal: soft & rounded • If distended? Why? • Tympany – gas • Dullness – fluid, solid mass • Umbilical hernia (umbilical ring) vs. • Diastasis recti (rectus abdominus)

  33. Detectable spleen • Can be common in well infants • Liver border • Newborn: just below R costal margin • Infants/toddlers: 1-3 cm below • Children: 1-2 cm below

  34. Note • Peristaltic waves • Pyloric stenosis? • Fixed solid mass… abdomen • Don’t palpate aggresively! • Wilm’s (nephroblastoma) • Neuroblastoma

  35. For each condition… • Know typical signs & symptoms • Clinical presentation • Significance? Referral? • Expected resolution? • Treatment?

  36. Exam Tips • To inspect the infant’s neck: • supine, elevate the upper back and let the head fall back into extension • To encourage an infant to open their eyes: • Dimly lit room • Hold infant upright, suspended, over a shoulder

  37. Exam Tips • Fundoscopic exam • Patient supine • Sit on parent’s lap? • Do not force eye open • Internal Ear Exam (infant) • Supine/prone, head turned • Rest ulnar surface of hand (otoscope) against face • Stabilize head • Pull auricle down

  38. Exam Tips • Auscultating lungs (need deep breaths) • Get them active • “blow out” pen light • Abdominal Exam • Bottle/pacifier/nursing • Supine on parent’s lap • If ticklish, place child’s hand under yours

  39. (There may be more than one answer for each…) • Clubbing (Schamroth technique) • Sign of _________? • Child with “barrel chest” • Sign of _________? • Skin turgor (abdomen) • Sign of _________?

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